American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News
for the Week of 2-2-10

Highlights

  • Most patients skip some insulin doses
  • Extended nicotine patch use doubles odds of quitting smoking at 24 weeks

Test yourself

  • MKSAP Quiz: intermittent claudication

Oncology

  • Symptoms aren’t always effective in diagnosing early ovarian cancer, study finds

Cardiology

  • NSAID does not reduce post-surgical pericardial effusion

Health care coverage

FDA update

From ACP Internist

  • The February issue of ACP Internist is online and coming to your mailbox

From Annals of Internal Medicine

  • Editors call for papers on 'healing Haiti'

From the College

  • Propose workshops for future meetings of Internal Medicine
  • New ACPNet project on low back pain
  • Practice improvement Webinars for the Medical Home Builder

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Most patients skip some insulin doses

A majority of patients taking insulin skip doses intentionally and about 20% do so regularly, according to a recent survey.

Researchers conducted an Internet survey of more than 500 U.S. adults who take insulin to treat type 1 or type 2 diabetes. In addition to quantifying the frequency with which insulin users skip doses, the survey identified some risk factors for insulin omission. Patients who were younger, had type 2 diabetes, had lower incomes and had more education were more likely to skip doses. Not following a healthy diet was also a risk factor, particularly for patients with type 1 diabetes. In addition, patients who reported that they took more injections, that their injections interfered with daily activities, and that pain and embarrassment were associated with injection were more likely to skip.

The results contradicted some common assumptions about insulin omission, as the survey found no differences according to race, gender or history of depression, although researchers noted that the nonwhite population in the study was small. The authors suggested that some of the other risk factors—such as pain and embarrassment—could be addressed by clinicians. Physicians should watch patients for risk factors of nonadherence and offer solutions such as insulin pens, finer-gauge needles and injection ports to prevent omission. The study was published in the February issue of Diabetes Care.

Patients’ low adherence to insulin regimens can cause a problematic cycle in which clinicians prescribe higher doses to manage glucose, noted an accompanying editorial. The authors said that the resistance of both physicians and patients in the U.S. to using insulin for type 2 diabetes needs to be better addressed, and called for the development of effective, brief interventions to improve adherence.

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Extended nicotine patch use doubles odds of quitting smoking at 24 weeks

Transdermal nicotine for 24 weeks compared to eight weeks doubled smoking cessation rates, reduced the risk for smoking lapses and increased the likelihood of recovery to abstinence after a lapse.

Transdermal nicotine is one of the most widely used smoking cessation treatments in the U.S. and Europe. Current guidelines recommend eight weeks of treatment, but the evidence is limited. Also, there is growing recognition that nicotine dependence is a chronic, relapsing condition that may require extended therapy to treat effectively.

To assess whether extended-duration transdermal nicotine therapy increases abstinence rates more than standard-duration therapy, researchers conducted a blinded, randomized, placebo-controlled trial of 568 adult smokers from September 2004 to February 2008. The smokers were randomized to standard therapy of Nicoderm CQ (GlaxoSmithKline, 21 mg) for eight weeks and placebo for 16 weeks, or extended therapy of the drug for 24 weeks. The research was funded by the National Institutes of Health, and results were reported in the Feb. 2 Annals of Internal Medicine.

The primary outcome was biochemically confirmed, point-prevalence abstinence at weeks 24 and 52. Secondary outcomes were continuous and prolonged abstinence, lapse and recovery events, cost per additional quitter and side effects and adherence.

At week 24, extended therapy produced higher abstinence rates (31.6% vs. 20.3%; odds ratio [OR], 1.81; 95% CI, 1.23 to 2.66; P=0.002), prolonged abstinence (41.5% vs. 26.9%; OR, 1.97; CI, 1.38 to 2.82; P=0.001), and continuous abstinence (19.2% vs. 12.6%; OR, 1.64; CI, 1.04 to 2.60; P=0.032) versus standard therapy.

Extended therapy reduced the risk for lapse (hazard ratio [HR], 0.77; CI, 0.63 to 0.95; P=0.013) and increased the chances of recovery from lapses (HR, 1.47; CI, 1.17 to 1.84; P=0.001). Time to relapse was slower with extended versus standard therapy (HR, 0.50; CI, 0.35 to 0.73; P<0.001). At week 52, extended therapy produced higher quit rates for prolonged abstinence only (P=0.027). There were no differences in side effects and adverse events.

The researchers concluded that since many persons resume smoking once they stop nicotine treatment, longer-term patch use should be considered. The extended therapy cost $2,482 per person, which compares well with costs of other smoking cessation treatments.

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Test yourself

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MKSAP Quiz: intermittent claudication

A 57-year-old woman is evaluated for intermittent claudication of the left calf that she has had for 5 years. The symptoms reproducibly occur after she walks 100 yards and resolve after 5 minutes of rest. The patient has an 80 pack-year smoking history but no longer smokes; she also has hypertension, type 2 diabetes mellitus, hypercholesterolemia, and chronic stable angina. Her medications include atenolol, atorvastatin, aspirin, lisinopril, and insulin.

On physical examination, the blood pressure is 142/94 mm Hg bilaterally and heart rate is 66/min. Carotid arteries are brisk, with a right carotid artery bruit. The lungs are clear to auscultation and percussion. There is an S4 and nonradiating 2/6 early systolic murmur at the left lower sternal border. Examination of the abdomen is normal. There is a left femoral artery bruit, with absent pulses in the left foot and trace pulses in the right foot.

What is the target blood pressure in this patient?

A) <140/85 mm Hg
B) <140/90 mm Hg
C) <130/90 mm Hg
D) <130/80 mm Hg

Click here or scroll to the bottom of the page for the answer and critique.

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Oncology

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Symptoms aren’t always effective in diagnosing early ovarian cancer, study finds

Using symptoms such as bloating and pelvic pain is not effective for early diagnosis of ovarian cancer, according to a recent study.

A 2007 consensus statement from the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists and the American Cancer Society recommended that women experiencing daily physical symptoms such as bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary frequency or urgency for more than a few weeks see a physician for evaluation for ovarian cancer. The statement was based on a symptom index proposed by an earlier study, which was considered positive when patients had at least one of several symptoms (pelvic or abdominal pain, increased abdominal size or bloating, and difficulty eating or feeling full) for less than a year but for more than 12 days a month. Researchers performed a population-based study to determine the sensitivity, specificity and positive predictive value of a symptom index and of the symptoms noted in the recommendation statement. The study results were published online Jan. 28 and will appear in the Feb. 24 Journal of the National Cancer Institute.

The authors interviewed 812 patients with epithelial ovarian cancer diagnosed between Jan. 1, 2002, and Dec. 21, 2005, and 1,313 population-based controls. The symptom index was considered positive when a woman had pelvic or abdominal pain, bloating, or feeling full daily for a least a week beginning less than a year before diagnosis or, for controls, a reference date. The consensus statement criteria were considered positive if a woman had any of these symptoms or urinary urgency or frequency for at least a month beginning less than a year before diagnosis or a reference date. Although patients with ovarian cancer were much more likely than those without to experience the index and consensus statement symptoms, these indicators were positive only within five months before diagnosis in most cases. The symptom index and consensus criteria were estimated to have a positive predictive value of less than 0.5% for early-stage disease and 0.6% to 1.1% overall.

The authors acknowledged several study limitations, including recall bias and the possibility that women with aggressive disease were not able to be interviewed. However, they concluded that evaluating patients for ovarian cancer based on physical symptoms is unlikely to lead to timely diagnosis. An accompanying editorial also noted the study’s limitations and pointed out that patients with ovarian cancer were 10 times more likely to have symptoms than those without. Still, the editorialists wrote, “These findings remind us that wide recognition of symptoms alone will not incrementally improve the overall survival from ovarian cancer. Rather, they highlight the urgent need to develop better molecular markers and improved imaging modalities for ovarian cancer screening.”

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Cardiology

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NSAID does not reduce post-surgical pericardial effusion

Diclofenac neither reduced the size of pericardial effusions nor prevented late cardiac tamponade in patients after cardiac surgery, according to a small study in France.

Asymptomatic pericardial effusion occurs in 50% to 85% of patients within a few days of cardiac surgery. Cardiac tamponade occurs in about 1% to 2% of patients, and may develop slowly and without clear-cut clinical signs. Most tamponade occurs more than seven days after surgery, by which time patients often have been discharged from the hospital.

While nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed and guidelines and reviews suggest their use, they've never been studied for this purpose. Although usually given for only a short time, they can cause serious adverse effects such as myocardial infarction, acute heart failure, acute renal failure and upper gastrointestinal tract bleeding or perforation.

To assess whether diclofenac is effective in reducing postoperative pericardial effusion volume, researchers supported by the French Society of Cardiology conducted a multicenter, randomized, double-blind, placebo-controlled study recruiting from five postoperative cardiac rehabilitation centers. They reported results in the Feb. 2 Annals of Internal Medicine.

Of the 5,455 patients screened, 196 patients met inclusion criteria. All 196 had moderate to large pericardial effusions more than seven days after cardiac surgery. Researchers randomized them to 50 mg of diclofenac or placebo twice daily for 14 days. Researchers administered transthoracic echocardiography upon admission and repeated it at 14 days after surgery, or earlier if they suspected tamponade.

The primary end point was mean change from baseline in the grade of pericardial effusion after 14 days of treatment. Secondary end points included frequency of tamponade, at least a 1-grade decrease in effusion, and mean change in millimeters of the width of effusion.

The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The groups showed similar mean decreases from baseline after treatment (−1.08 grades [SD, 1.20] for the placebo group vs. −1.36 [SD, 1.25] for the diclofenac group). The mean difference between groups was insignificant at −0.28 grade (95% CI, −0.63 to 0.06 grade; P=0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and nine in the diclofenac group (P=0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site and type of surgery. No patients had recognized gastrointestinal hemorrhage. The mean increase in hemoglobin level was 0.46 mmol/L (SD, 0.62) in the placebo group versus 0.170 mmol/L (SD, 0.63) in the diclofenac group (P=0.002), which is consistent with subclinical gastrointestinal bleeding in patients receiving diclofenac.

Based on the results, the researchers recommended that doctors stop prescribing NSAIDs for post-surgical pericardial effusion because they have no clear benefit. Although the study suggests NSAIDs are not useful for this condition, researchers acknowledged that the study was underpowered to detect small beneficial effects from diclofenac or to evaluate adverse clinical events from the drug.

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Health care coverage

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Higher copayments lead to more hospitalizations

Increasing copayments for outpatient care increases elderly patients’ use of hospitals and ups overall health care expenditures, a new study found.

The longitudinal research compared expenditures by enrollees in Medicare plans that increased copayments for ambulatory care with those in similar plans that made no changes. About 900,000 patients from 36 plans were included in the study, which ran from 2001 to 2006. In the plans that increased copayments, the average payments nearly doubled: from $7.38 to $14.38 for primary care and from $12.66 to $22.05 for specialty care.

In the year after the cost increases, the increased-cost plans had 19.8 fewer outpatient visits per 100 enrollees than the control (no-increase) plans. However, the plans that increased copayments also had 2.2 additional annual hospital admissions per 100 enrollees, 13.4 more inpatient days per 100, and 0.7% more enrollees who were hospitalized. The effects were magnified among enrollees living in areas of lower education and income and among patients who had hypertension, diabetes or a history of myocardial infarction. The study was published in the Jan. 28 New England Journal of Medicine.

The findings indicate that cost sharing initiatives for Medicare patients may have an adverse effect on both health and overall spending, study authors concluded. Even using the bounds of the study’s 95% CIs, they calculated that additional expenditures for hospital care would definitively outweigh savings from the copayment increase. These results were found despite high-spending enrollees leaving the higher-copayment plans after the change, and increases in the copayment for inpatient care in those plans—two factors that might have been expected to reduce inpatient expenditures.

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United and Aetna to continue paying consultation codes

UnitedHealthcare and Aetna both recently announced that, contrary to Medicare policy, they will continue to pay for CPT consultation codes under their commercial plans.

On Jan. 1, CMS removed the consultation codes from the Medicare Physician Fee Schedule. In lieu of the consultation codes, CMS has instructed physicians to begin billing for corresponding office and hospital visit evaluation and management codes. Additional information about the changes to consultation codes and other changes to Medicare for 2010 can be found on the Running a Practice section of the ACP Web site.

The practice management sections of the January and February issues of ACP Internist include additional information about recent changes to coding regulations.

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FDA update

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Nipro syringes and needle sets recalled

A number of insulin syringes and infusion needle sets are being recalled by manufacturer Nipro Medical Corporation, the FDA announced last week.

The Glucopro syringes may have needles that detach and then become stuck in the insulin vial, push back into the syringe, or remain in the skin after injection. The recall includes all product codes and lot numbers with expiration dates before 2011-11 (Nov. 1, 2011).

The class I recall of needle sets includes Exel/Exelint Huber needles, Exel/Exelint Huber Infusion Sets and Exel/Exelint “Securetouch+” Safety Huber Infusion Sets. These needles should be designed to penetrate implanted ports without cutting and dislodging any silicone cores or slivers. However, inspections conducted in October 2009 of Nipro facilities in Japan found that their needles “cored” in 60% to 72% of tests, the FDA said.

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Sibutramine contraindicated in patients with CVD

Patients who have a history of cardiovascular disease and take sibutramine hydrochloride (Meridia) have an increased risk of heart attack and stroke, a recent FDA review concluded.

The drug label will be changed to add a new contraindication stating that sibutramine is not to be used in patients with a history of cardiovascular disease, including coronary artery disease, stroke or transient ischemic attack, heart arrhythmias, congestive heart failure, peripheral arterial disease, or uncontrolled hypertension.

Health care professionals should regularly monitor the blood pressure and heart rate of patients using sibutramine and if sustained increases are observed, the drug should be discontinued. Additionally, sibutramine should be discontinued in patients who do not lose at least 5% of their baseline body weight within the first three to six months of treatment, as continued treatment is unlikely to be effective and exposes the patient to unnecessary risk, the FDA advised.

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From ACP Internist

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The February issue of ACP Internist is online and coming to your mailbox

February's issue of ACP Internist is online, with coverage of:

Calmer talk needed about mammography. Controversy about implementing new mammography guidelines shouldn’t cloud talks between doctors and the women they counsel. Clarify what the guidelines really say, and share the decision-making with patients, experts say.

Med schools promoting care for underserved. To encourage primary care careers, medical schools are offering students shortened specialty rotations in favor of fast-track graduation, half-tuition forgiveness and having students follow patients through the health system. Different teaching models emphasize continuity of care over snapshots of diagnoses, and place students in the clinics where they can fulfill the nation’s need for rural care.

Army physicians on the front lines of infectious disease research. Walter Reed’s infectious disease unit travels the globe to identify and combat the world’s deadliest infectious diseases. Initiated to find vaccines that protect troops stationed overseas, the work quickly benefits civilian populations, too.

Read these and other stories online at www.acpinternist.org, and follow ACP's blog and Twitter feed.

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From Annals of Internal Medicine

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Editors call for papers on 'healing Haiti'

Annals of Internal Medicine's editors have issued a call for papers addressing Haiti's recovery after the recent earthquake, the journal announced last week.

The editors are soliciting manuscripts that examine Haiti's immediate and long-term challenges, as well as critically examine how this crisis may influence internal medicine in coming years. Thoughtful commentaries, original research articles, and scholarly reviews that inform the question “What can we do to help heal Haiti?” are welcomed for consideration. Questions about potential submissions should be directed to Dr. Deborah Cotton.

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From the College

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Propose workshops for future meetings of Internal Medicine

The Clinical Skills Subcommittee (CSSC) is now accepting proposals for Internal Medicine 2011, April 7-9, 2011. The CSSC welcomes all proposals but places a priority on interactive workshops that focus on the acquisition or improvement of physical examination skills, communication skills and procedural skills. The CSSC is most interested in workshops that have a high likelihood of changing physician behavior using proven teaching techniques or new and innovative teaching strategies that have yet to be tested. The deadline for proposals is May 1, 2010. Download the proposal form.

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New ACPNet project on low back pain

ACP has introduced a new program in its ACPNet series, one of ACP’s most long-lasting and popular online practice and quality improvement programs.

The ACPNet Low Back Pain Education Project aims to help physicians in their evaluation and management of patients with low back pain. The Web-based project offers eight CME credits and involves two surveys, one taken after a review of the material, and one six weeks following completion of the educational module. The educational module encompasses information on diagnosis and evaluation of low back pain, utility of diagnostic imaging, assessment of pain and function, management of low back pain, shared decision making, and referral and follow-up. More than 1,600 ACP members in 50 states use ACPNet to analyze practice patterns, learn quality improvement techniques, and improve patient management. The ACPNet Low Back Pain Education Project is recognized by Wellpoint, Inc for their provider recognition program.

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Practice improvement Webinars for the Medical Home Builder

ACP has just announced a new series of quality improvement Webinars, “Charting Your Way to Practice Improvement: Webinars for the 21st Century Patient-Centered Practice.” Available at no charge to users of the ACP Medical Home Builder and their staff, the interactive Webinars will cover why quality improvement should be important to your practice and practical ways you can improve your practice.

The first Webinar will be held tonight, Feb. 2 at 6 p.m., with the series continuing through the summer. Additional information about the series is available online. Also, for more information about the Medical Home Builder and how this quality improvement tool may be able to help your practice, please visit the Running a Practice section of ACP’s Web site.

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Cartoon caption contest

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And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Steven J. Meyerson, ACP Member, an internist specializing in geriatrics at Baptist Hospital of Miami. He will receive a $50 gift certificate good toward any ACP product, program or service. He won previously in November 2007. Readers cast 113 ballots online to choose the winning entry. Thanks to all who voted!


"I know, sir. A lot of our patients feel that way about their health plans."

The winning entry captured 57.5% of the votes.

The runners-up were:

"Thanks, but I think I'll go with accu-pressure next time."
"Only when I laugh."

ACP Internist continues its cartoon caption contest next week.

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MKSAP answer and critique

The correct answer is D) <130/80 mm Hg. This item is available online to MKSAP 14 subscribers in the Cardiovascular section, Item 118.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

Hypertension is an independent risk factor for peripheral artery disease, and current guidelines support aggressive blood pressure management. For the general population, blood pressure targets of <140/90 mm Hg are associated with a decrease in cardiovascular complications, with target pressures of <130/80 mm Hg in patients with diabetes or renal failure.

Lifestyle modification (weight reduction, potassium- and calcium-rich diet, sodium restriction, physical activity, moderation of alcohol consumption) may all contribute to blood pressure control. Thiazide-type diuretics should generally be used as initial therapy for most patients with hypertension, either alone or in combination with an angiotensin-converting enzyme inhibitor, an angiotensin receptor blocker, a ß-blocker, or a calcium-channel blocker.

Key point

  • The target pressure for patients with diabetes mellitus or renal failure is <130/80 mm Hg.

Click here to return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright 2010 by the American College of Physicians.

Test yourself

A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?

Find the answer

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